Extubation in OR SHAJI SAINUDEEN RASHID HOSPITAL, DUBAI

NO YES Is tracheal extubation a problem ? Difficult extubation : 208 references Difficult intubation : 3022 references (x 14.5) YES Morbidity factor related to anesthesia

Incidence of death, brain damage, and nerve injury as a percentage of total claims Cheney FW Anesthesiology 1999

Incidence of respiratory, cardiovascular, and equipment-related damaging events as a percentage of the total claims for death and brain damage Cheney FW Anesthesiology 1999

T : 1/145 500 P : 1/21 200

Management of the Difficult Airway A Closed Claims Analysis Peterson GNet al. Anesthesiology 2005

Respiratory complications associated with tracheal intubation or extubation Asai et Col BJA 1998 Induction Extubation OR Extubation PACU Cough 1.5 % 6.6 % 3.1 % SpO2< 90 1.1 % 2.4 % 2.2 % Laryngo- Spasm 0.4 % 1.7 % 0.8 % DV 1.4 % - - DI 0.8 % - - Airway Obstruction - 1.9 % 3.8 % 1 compli- cation 4.6 % 12.5 % 9.5 %

An Analysis of Reintubations from a Quality Assurance Database of 152,000 patients P Lee et al J clin Anesth 2000 N=191 (1/1000) OR PACU OR+PACU % Respiratory 48 64 112 58 complications Unintentional 25 0 25 13 Extubation Surg Compl. 10 6 16 8 Neurom. blocking 4 7 11 6 Opioïd residual 2 7 9 5 Upper airway obst. 8 0 8 4 Cardiac complications 2 0 2 1

EMERGENCY TRACHEAL INTUBATION IN PACU 13593 admission to PACU from October 1986-Oct 1988. 26(0.19%) required reintubation in PACU. 20/26 (77%) within 1hr of extubation and/or admission to PACU. Reintubation was common in extremes of age. 54% more than 60yrs, 19% less than 3yrs. 23% of the reintubated underwent ENT procedures. 18/26 (69%) were directly related to anaesthetic management. Mathew, Anesth Analg. 1990

All problems related to anesthesia were considered preventable 315 incidents or accidents (0,4%) 111 totally related to anesthesia 27 during recovery (oxygen desaturation, airway patency problem) and 8 totally due to anesthesia Inappropriate extubation : residual effect of muscular relaxant or anesthetetic agents (misjudgment), laryngospasm or bronchospasm aspiration All problems related to anesthesia were considered preventable

Analysis of reintubations Respiratory complications were the most common cause of reintubation in the perioperative period. More reintubations occured in the immediate post extubation phase. Muscle relaxant effect and opioid effect are rare causes of respiratory failure in the anaesthetized patient in the immediate postoperative period. Anaesthesia related problems in immediate post extubation phase is preventable

CAUSES OF FAILED EXTUBATION Several attempts for difficult intubation. Traumatic intubation. Large diameter,overinflation,malposition of endotracheal tube. Prolonged surgery( more than 4hrs). Emergency surgery. Cervicomaxillofacial surgery. Prolonged trendelenberg position Radiotherapy and neck dissection.

EXTUBATION FAILURE Prevention better than treatment. Be aware of the factors that predict extubation outcome to improve clinical decision making. Rapid reinstitution of ventilatory support in patients who fail extubation may improve outcome. Rothar and Epstein- current opinion in crit care, 2003

Management of extubation Extubation criteria Appropriate technique Anticipate difficult extubation(DE) Management of DE

Tracheal Extubation criteria No residual neuromuscular blockade Respiratory Criteria Cardiovascular Criteria General criteria Level of conciousness

Tracheal Extubation criteria No residual neuromuscular blockade Head lift 5 sec TOF ratio > 0.9 +++ DBS 2

Residual Paralysis in the PACU after a Single Intubating Dose of Nondepolarizing Muscle Relaxant with an Intermediate Duration of Action Residual paralysis rate 37 Debaene B et Col Anesthesiology 2003

Murphy G S et al. Anesth Analg 2005;100:1840-1845 Train-of-four (TOF) ratios measured immediately before tracheal extubation and again on admission to the postanesthesia care unit (PACU). Figure 1. Train-of-four (TOF) ratios measured immediately before tracheal extubation and again on admission to the postanesthesia care unit (PACU). The graphs illustrate the number of patients (of a total of 120) with TOF ratios <0.7, 0.8, and 0.9 at each measurement interval. Murphy G S et al. Anesth Analg 2005;100:1840-1845 ©2005 by Lippincott Williams & Wilkins

Residual paralysis at the time of tracheal extubation. Murphy G.S Complete recovery from neuromuscular blockade is rarely present at the time of tracheal extubation. Respiratory and pharyngeal function do not normalize until TOF ratios of 0.8–1.0 are obtained. Anesth Analg. 2005 Jun;100(6):1840-5

Tracheal Extubation criteria Respiratory Criteria - steady spontaneous breathing without difficulty - VT > 6 ml.kg-1 - respiratory rate 12 to 25 c/min-1 - negative inspiratory pressure < -20 à -30 cmH2O - SpO2 >95 % (air)

Tracheal Extubation criteria Cardiovascular Criteria HR and arterial pressure ± 20 % of baseline values No vasopressor or inotropic drug General criteria temperature > 36° C pain control no surgical complications (bleeding, hematoma…)

Tracheal Extubation criteria Level of conciousness Fully awake vs deep extubation Considerations Any difficulty in controlling airway Any risk of aspiration Awake Incidence of respiratory complication less Deep Sympathetic response less Increased airway complications

Tracheal Extubation Appropriate Technique Extubation manoeuvre Position ???..... Oxygénation FiO2 =1 during few minutes buccal, pharyngeal and tracheal suctions 3 periods : • 2 to 3 deep inspirations (recruiting manœuvre) • deflate cuff of ET • take off the ET at the end of inspiration to minimize the risk of laryngospasm (without suction+++)

How to anticipate a difficult tracheal extubation? Complications related to the patient and/or surgery Difficult Intubation - Anticipate Difficult Extubation

Risk factors of difficult tracheal extubation Related to the patient Difficult mask ventilation during induction Difficult Intubation Traumatic Intubation Upper airway oedema or tumor Increased risk number of attempts > 3 ++++

Risk factors of difficult tracheal extubation Related to the surgery (ENT, head and face ) Local : oedema, hematoma, VC paralysis Expected difficulties : jaw immobilisation

Predicting difficult extubation.. LEAK = 0 Oedema VT expired = VT inspired Cuff-leak test VT expired < VT inspired Tracheal intubation > 48 h leak > 12-15 % OK leak < 12-15 % increased risk of stridor and/or reintubation Leak with deflated cuff Jaber S et Col Intensive Care Med 2003

Predicting difficult extubation.. Cuff-leak test Cuff-leak test for the diagnosis of upper airway obstruction in adults: a systematic review and meta-analysis. A positive cuff-leak test (absence of leak) should alert the clinician of a high risk of upper airway obstruction. Intensive Care Med ,2009

Laryngeal ultrasound: a useful method in predicting post-extubation stridor Ding LW Eur Respir J .2006

Laryngeal ultrasound- no oedema

Laryngeal ultrasound- with oedema Inflated cuff Deflated cuff

Predicting difficult extubation.. Spontaneous Breathing trial T piece 30 – 45 minutes

Contribution of the Endotracheal Tube and the Upper Airway to Breathing Workload STRAUS C et al. AM J RESPIR CRIT CARE MED 1998 Total WOB A 2-h trial of spontaneous breathing through an ETT tube well mimics the WOB performed after extubation

Strategies for difficult extubation Tracheal tube exchange catheter/gum elastic bougie Extubation over flexible bronchoscope through an LMA

Anticipated difficult extubation Cook ® airway exchanger

Conclusion Respiratory adverse events are more frequent during tracheal extubation than during anesthesia induction. Tracheal extubation is a routine manœuvre but required full attention to prevent respiratory complications. Difficult intubation = anticipate difficult extubation Difficult extubation should be anticipated with a predefined strategy.

Safe landing is equally important